Inside Health

Campaign Touts the Benefits of Folic Acid

By ERIC NAGOURNEY

Published: December 12, 2000

In the 1980's, federal health officials published a map of sorts that set off alarm bells in South Carolina.

''We had double the national rate of neural tube defects, so South Carolina was considered the hot spot in the nation,'' said Maureen Vicaria, a March of Dimes official in the state. ''If you looked at the map of the United States, there was this bull's-eye in South Carolina.''

This was a matter of no small concern. Neural tube defects are birth defects that range from spina bifida, a generally survivable but crippling disease, to the generally fatal anencephaly and encephalocele, in which the skull and brain do not develop properly.

Then, earlier this year, officials announced that South Carolina had succeeded in cutting in half its neural tube defect rate after an ambitious public education program that encouraged women to take supplements of folic acid, a B vitamin that can prevent most of the incidences of the defect. From 1992 to 1998, neural tube defect cases in the state decreased to 0.95 per 1,000 live births and fetal deaths, from 1.89.

The public education campaign, conducted by the state government and private groups, has been lauded as a model of what should be used across the country. It has, in fact, helped shape a much broader national campaign to promote the use of folic acid that the March of Dimes began coordinating about two years ago.

But if there is celebrating going on in South Carolina by the people behind the success, it is muted. While the achievements there show what can be accomplished with enough effort, they also show just how hard it can be for enterprises of this sort to change people's behavior.

''We are happy with it,'' said Dr. Roger E. Stevenson, one of the leaders of the effort. ''But we are not happy with the fact that we are not at the end position we want to be.''

The problem is that the goal of the South Carolina campaign (as well as the national one) is to persuade all women of childbearing age to take 400 micrograms of folic acid every day. Initially, the rate of women taking the supplement climbed from 8 percent in 1992 to about 35 percent in 1998. But, officials said, the rates have now leveled off.

''The campaign in South Carolina to reach all women of reproductive age was a success and a failure,'' said a commentary in the October issue of the journal Pediatrics. In the same issue, Dr. Stevenson, director of the Greenwood Genetic Center in South Carolina, described the gains the state has made.

Part of the difficulty is that while it is relatively easy to reach women contemplating having a baby by putting materials at, for example, bridal registries, it is much harder to get through to women who do not intend to become pregnant -- about half of all those who do, studies suggest.

Folic acid, however, is effective only at very beginning of the pregnancy, when crucial neurological development is taking place, and when most women do not even know they are pregnant.

Dr. Stevenson believes that the neural tube defect rate in his state can be halved again, if only folic acid intake can be increased. (No one believes that the defects can be prevented entirely, however.)

The state now spends about $1 million a year on its folic acid campaign, and by some estimates it has reduced medical costs associated with neural tube defects by $15 million or more per year.

Neural tube defects of all types affect some 4,000 pregnancies a year in the United States and 2,500 births. No one is sure why they were occurring disproportionately in South Carolina.

The South Carolina program has involved billboards, television advertisements, programs on college campuses and health-care providers who have been encouraged to raise the issue with their patients. Although the state has brought down its birth defect rate through the campaign, some experts say the real solution lies elsewhere.

Groups like the March of Dimes have lobbied the federal Food and Drug Administration to require that cereals and grains be supplemented with folic acid. Two years ago, the F.D.A. did just that, but some birth defect experts say the agency did not set the levels high enough. While recent studies have shown that women are averaging greater blood levels of folates, presumably because of the new requirements, there are no figures yet on changes in the rates of neural tube defects.

Folic acid is also available naturally, in foods like citrus fruit, leafy green vegetables and beans. But the body does not always metabolize them properly.

And although some folic acid campaigns have sought to teach women about what foods to eat, Ms. Vicaria, the director of program services for the March of Dimes in South Carolina, said supplements were the most reliable answer.

''Frankly,'' she said, ''we don't promote food as the only answer. We always say, 'a healthy diet including these foods, plus a multivitamin.' I think it's a disservice to the public to send out the message that if you eat a healthy diet and focus on these foods alone, you can prevent neural tube defects.''